Intended for healthcare professionals


Care of dying review shows shortcomings in palliative care

BMJ 2014; 348 doi: (Published 15 May 2014) Cite this as: BMJ 2014;348:g3262
  1. Ingrid Torjesen
  1. 1London

Most hospitals have not put in place some of the fundamental elements needed to help ensure a “good” death for patients, such as seven day access to specialist palliative care and mandatory training for staff caring for dying patients, an audit led by the Royal College of Physicians has found.

The audit was funded by Marie Curie Cancer Care and Public Health England, and its findings, published on 15 May, showed that just one in five hospitals (21%) had face to face palliative care services available seven days a week, despite a longstanding recommendation that they be provided.1 Most hospitals (73%) provided face to face services on weekdays only.

Mandatory training in caring for dying patients was a requirement for doctors at only 19% of trusts and for nurses at only 28%. In the past year, 18% had provided no such training at all.

The audit’s report, The National Care of the Dying Audit for Hospitals, recommended that hospitals should provide face to face specialist palliative care services at least from 9 am to 5 pm, seven days a week.2 In addition, education and training in caring for dying patients should be mandatory for all staff who care for dying patients, and this should include training in communication skills, as well as skills for supporting the patients’ families and friends.

To improve services the report said that a local audit of the care of dying patients—including assessing bereaved relatives’ views—should be done at least annually. It added that trust boards should formally receive and discuss this local audit and should have a designated board member and a lay member with specific responsibility for the care of dying patients. Currently, only 53% of trusts had a board member with this responsibility. In the past year only 58% of boards had discussed end of life care, and just 56% had carried out a formal audit.

Jane Collins, chief executive of Marie Curie Cancer Care, said, “There’s only one chance to get people’s care at the end of their lives right, but we know that our hospitals do not always provide the high quality care and dignified death that we all have the right to expect. The recommendations of the audit are clear. In particular, more needs to be done to improve governance, staff training, and access to pastoral and specialist palliative care teams.”

The national audit, carried out by the Royal College, in collaboration with the Marie Curie Palliative Care Institute in Liverpool, assessed the quality of care given to 6580 people who had died in 149 hospitals in England between 1 and 31 May 2013, in cases where the death was expected.

The audit included a review of the case notes of a sample of patients; a questionnaire completed by 858 bereaved relatives or friends about the treatment of the patient, their involvement in decision making, and the support available to them; and details about the organisation of care, including the availability of palliative care services, staff numbers, training, and responsibilities for care.

The case note review showed that, in 87% of cases, healthcare professionals had recognised that patients were in their last days of life but that less than half (46%) of patients capable of discussing this had been told. And just 21% of such patients were asked about their spiritual needs.

Communication with family and friends about the impending death of their relative or friend was found to be better, occurring in 93% of cases, and on average, 31 hours before the death.

Kevin Stewart, chairman of the audit steering group and clinical director of the Royal College’s Clinical Effectiveness and Evaluation Unit, said, “I am deeply concerned that some hospitals are falling short of the excellent care that should be provided to dying people and those important to them. In particular, communication with patients and their families is generally poor. It is disappointing that hospitals don’t seem to recognise this as an important issue.”

Most patients (63-81%) had medication prescribed “as required” for the five key symptoms often experienced near the end of life: pain, agitation, noisy breathing, difficulty in breathing (shortness of breath or dyspnoea), and nausea and vomiting. In the last 24 hours of life 44% of patients received pain relief and 17% received medication for shortness of breath.

The report said that the decision that a patient is in the last hours or days of life should be made by the multidisciplinary team and documented by the senior doctor responsible for the patient’s care. It added that a discussion should take place with the patient where possible and appropriate and with the family, carers, or other advocates.

Control of pain and other symptoms in dying patients should be assessed at least every four hours and medication given promptly if necessary, the report recommended. However, it added that decisions about the use of clinically assisted (artificial) nutrition and hydration were complex and should be taken by a senior experienced clinician with the support of a multidisciplinary team.

The audit found that 59% of patients were clinically assessed to see if they needed artificial hydration and 45% for artificial nutrition. However, in both cases this was recorded as having been discussed with only 17% of patients capable of having the conversation and with about twice as many relatives and friends (36% for artificial hydration and 29% for artificial nutrition).


Cite this as: BMJ 2014;348:g3262


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